Local437.ca



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SHEET METAL WORKERS INTERNATIONAL ASSOCIATION,

LOCAL 437 HEALTH AND OTHER INSURANCE BENEFITS TRUST

Great-West Life is a leading Canadian life and health insurer. Great-West Life's financial security advisors work with our clients from coast to coast to help them secure their financial future. We provide a wide range of retirement savings and income plans; as well as life, disability and critical illness insurance for individuals and families. As a leading provider of employee benefits in Canada, we offer effective benefit solutions for large and small employee groups.

Great-West Life Online

Information and details on Great-West Life's corporate profile, our products and services, investor information, news releases and contact information can all be found at our website .

This booklet describes the principal features of the group benefit plan sponsored by your employer, but Group Policy No. 162767 issued by Great-West Life is the governing document. If there are variations between the information in the booklet and the provisions of the policy, the policy will prevail.

This booklet contains important information and should be kept in a safe place known to you and your family.

The Plan is underwritten by

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and arranged and administered by

Belmont Financial Group

133 Prince William Street Suite #605

Saint John, NB E2L 2B5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

300-08-10

Protecting Your Personal Information

At Great-West Life, we recognize and respect the importance of privacy. When you apply for coverage or benefits, we establish a confidential file of personal information. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law.

We use the personal information to administer the group benefit plan under which you are covered. This includes many tasks, such as:

• determining your eligibility for coverage under the plan

• enrolling you for coverage

• assessing your claims and providing you with payment

• managing your claims

• verifying and auditing eligibility and claims

• underwriting activities, such as determining the cost of the plan, and analyzing the design options of the plan

• preparing regulatory reports, such as tax slips

We may exchange personal information with your health care providers, your plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us when necessary to administer the plan.

All claims under this plan are submitted through you as plan member. We may exchange personal information about claims with you and a person acting on your behalf when necessary to confirm eligibility and to mutually manage the claims.

For more information about our privacy guidelines, please ask for Great-West Life’s Privacy Guidelines brochure.

MEMBER CLASSES

| |

|Division 1 – Sheet Metal Workers and Division 2 - Roofers |

|Description |Benefit Class |

| |Number |

|Working , Full Benefits |1 |

|Non-Working, Full Benefits, No Disability |2 |

|Retired, No Drugs/Dental/Disability |3 |

|Totally Disabled, Full Benefits, except Disability |5 |

|Self-Pay Full Benefits |6 |

|Non-Working, No Dental/Disability |7 |

|Retired, With Drugs, No Dental/Disability |8 |

|Totally Disabled, Full Benefits, except Disability/Dental |9 |

|Salaried, Full Benefits |16 |

| |

TABLE OF CONTENTS

Page

Benefit Summary

Commencement and Termination of Coverage

Dependent Coverage

Member Life Insurance

Dependent Life Insurance

Accidental Death, Dismemberment and

Specific Loss (AD&D) Insurance

Short Term Disability (STD) Income Benefits

Long Term Disability (LTD) Income Benefits

Healthcare

Preferred Vision Services (PVS)

Dentalcare

Coordination of Benefits

Diagnostic and Treatment Support Services (Best Doctors® Service)

Benefit Summary

This summary must be read together with the benefits described in this booklet.

Member Life Insurance

Benefit Classes 1, 2, 5, 6, 7, 9, 16 $40,000

Benefit Classes 3, 8, 30 $10,000

Dependent Life Insurance

Benefit Classes 1, 2, 5, 6, 7, 9, 16

Spouse $10,000

Child $5,000

Benefit Classes 3, 8, 30

Spouse $1,000

Child $1,000

Accidental Death,

Dismemberment and Specific Loss

(Principal Sum)

Benefit Classes 1, 2, 5, 6, 7, 9, 16 $50,000

Benefit Classes 3, 8, 30 No Coverage

Short Term Disability Income Benefits

Benefit Classes 1 and 16

Waiting Period

Injury No waiting period

Disease 7 days

If you are hospitalized or have day surgery before the last day of the waiting period for disease, benefits will begin on the day you are hospitalized or the surgery is performed

Maximum Benefit Period 26 weeks less the number of full or partial weeks’ payment under the Employment Insurance Act of Canada

Amount during any period which

Employment Insurance Act benefits

would be payable if you qualified $250 weekly

Amount during any other period $360 weekly

Benefit Classes 2, 3, 5, 6, 7, 8, 9, 30 No Coverage

Long Term Disability Income Benefits

Benefit Classes 1 and 16

Waiting Period 182 days

Amount $800 monthly

Benefit Classes 2, 3, 5, 6, 7, 8, 9, 30

No Coverage

Healthcare

Covered expenses will not exceed customary charges

Benefit Classes 1, 2, 5, 6, 7, 9, 16, 30

(non-retired employees)

Deductible Nil

Reimbursement Level 100%

Basic Expense Maximums

Home Nursing Care $10,000 each calendar year

In-Canada Prescription Drugs Included

Vaccines $500 each calendar year

Smoking Cessation Products $500 lifetime when prescribed by a physician

Fertility Drugs $2,500 lifetime

Hearing Aids $500 every 5 years

Speech Aids $1,000 lifetime

Insulin Infusion Pumps $5,500 per pump once every 5 years

Insulin Jet Injectors $1,000 lifetime

Custom-fitted Orthopedic Shoes 1 pair each calendar year

Custom-made Foot Orthotics $400 each calendar year

Myoelectric Arms $10,000 per prosthesis

External Breast Prosthesis 1 every 12 months

Surgical Brassieres 2 every 12 months

Mechanical or Hydraulic Patient

Lifters $2,000 per lifter once every 5 years

Electric Wheelchairs $10,000 every 5 calendar years

Outdoor Wheelchair Ramps $2,000 lifetime

Blood-glucose Monitoring Machines 1 every 4 years

Transcutaneous Nerve Stimulators $700 lifetime

Extremity Pumps for Lymphedema $1,500 lifetime

CPAP Machines $2,500 every 5 years

Custom-made Compression Hose $250 each calendar year

Wigs for Cancer Patients $200 lifetime

Paramedical Expense Maximums

Acupuncturists $500 each calendar year

Chiropractors $500 each calendar year

Massage Therapists $500 each calendar year when referred by a doctor

Naturopaths $500 each calendar year

Osteopaths $500 each calendar year

Physiotherapists/Athletic Therapists $500 each calendar year

Podiatrists $500 each calendar year

Psychologists/Social Workers $500 each calendar year

Audiologists $500 each calendar year

Visioncare Expense Maximums

Eye Examinations

-dependent children

under age 19 1 every 12 months

-all others 1 every 24 months

Eye Examinations, Glasses

and Contact Lenses

-dependent children

under age 19 $300 every 12 months

-all others $300 every 24 months

Laser Eye Surgery $600 lifetime

Contact Lenses for Special

Conditions $300 every 24 months

Lifetime Healthcare Maximum Unlimited

Benefit Classes 3 and 8

(retired employees)

Deductible Nil

Reimbursement Level 100%

Basic Expense Maximums

Home Nursing Care $10,000 each calendar year

In-Canada Prescription Drugs Included*

Vaccines $500 each calendar year*

Smoking Cessation Products $500 lifetime when prescribed by a physician*

Fertility Drugs $2,500 lifetime*

*Benefit Class 3 is not eligible for Prescription Drugs

Hearing Aids $500 every 5 years

Speech Aids $1,000 lifetime

Insulin Infusion Pumps $5,500 per pump once every 5 years

Insulin Jet Injectors $1,000 lifetime

Custom-fitted Orthopedic Shoes 1 pair each calendar year

Custom-made Foot Orthotics $400 each calendar year

Myoelectric Arms $10,000 per prosthesis

External Breast Prosthesis 1 every 12 months

Surgical Brassieres 2 every 12 months

Mechanical or Hydraulic Patient

Lifters $2,000 per lifter once every 5 years

Electric Wheelchairs $10,000 every 5 calendar years

Outdoor Wheelchair Ramps $2,000 lifetime

Blood-glucose Monitoring Machines 1 every 4 years

Transcutaneous Nerve Stimulators $700 lifetime

Extremity Pumps for Lymphedema $1,500 lifetime

CPAP Machines $2,500 every 5 years

Custom-made Compression Hose $250 each calendar year

Wigs for Cancer Patients $200 lifetime

Paramedical Expense Maximums

Acupuncturists $100 each calendar year

Chiropractors $100 each calendar year

Massage Therapists $100 each calendar year when referred by a doctor

Naturopaths $100 each calendar year

Osteopaths $100 each calendar year

Physiotherapists/Athletic Therapists $100 each calendar year

Podiatrists $100 each calendar year

Psychologists/Social Workers $100 each calendar year

Speech Therapists $100 each calendar year

Visioncare Expense Maximums

Eye Examinations

-dependent children

under age 19 1 every 12 months

-all others 1 every 24 months

Eye Examinations, Glasses

and Contact Lenses

-dependent children

under age 19 $300 every 12 months

-all others $300 every 24 months

Laser Eye Surgery $600 lifetime

Contact Lenses for Special

Conditions $300 every 24 months

Lifetime Healthcare Maximum Unlimited

Dentalcare

Benefit Classes 1, 2, 5, 6, 16, 30

Covered expenses will not exceed customary charges

Payment Basis The dental fee guide in effect in your province of residence one year prior to the date treatment is rendered

Deductible Nil

Reimbursement Levels

Basic Coverage 100%

Major Coverage 80%

Accidental Dental Injury Coverage 100%

Plan Maximums

Accidental Dental Injury Treatment Unlimited

All Other Treatment $1,000 each calendar year

Benefit Classes 3, 7, 8, 9 No Coverage

COMMENCEMENT AND TERMINATION OF COVERAGE

To Be Eligible For Coverage You Must Be:

• An active member in good standing of the Union and employed by a participating employer in a job class covered by a labour contract or collective agreement with the Union;

• A permanent full-time salaried employee of the Union;

• A non-union employee hired by a participating employer to meet short-term requirements, who performs the usual duties of a Union member;

• A full-time employee of a participating employer;

• A Canadian resident covered by a Provincial health insurance plan; or

• A retired member in good standing of the Union who:

▪ is at least 60 years of age;

▪ has been certified as such by the Union;

▪ who contributes under a self payment program (in this case such retired members may be eligible for reduced Life insurance for themselves and their dependents and reduced Health Care Benefits only); and

▪ was insured as an active member for the 12 month period immediately preceding retirement (spouse of employee must also be covered immediately preceding retirement).

Effective Date of Coverage

• Hour Bank Requirements:

You will become eligible for coverage on the first day of the month following the date you have accumulated at least 200 credited hours in your Hour/Dollar Bank Account and the Trustees have allocated sufficient funds to your Hour/Dollar Bank Account to cover the monthly cost of providing benefits. A member must accumulate 130 hours per month of Active Employment for continued coverage.

On the first day of each month, sufficient funds to cover the current monthly cost of benefits will be deducted from your Hour/Dollar Bank Account. If there are insufficient funds in your Hour/Dollar Bank Account to cover the current monthly cost of benefits, your coverage will lapse as of the end of the previous month.

You may accumulate a maximum equivalent to 20 times the current monthly cost of benefits in your Hour/Dollar Bank Account. Excess amounts will be credited as follows, 75% to your registered pension plan and 25% to the general reserves of the Trust Fund.

Your benefits will continue after you stop working until the funds in your Hour/Dollar Bank Account are insufficient to cover the current monthly cost of benefits. If no amounts are allocated to your Hour/Dollar Bank Account during the 12 month period following termination of your coverage, any amount in your Hour/Dollar Bank Account after expiry of the 12 month period will be credited to the general reserves of the Trust Fund.

The monthly cost of benefits may vary from time to time. Please contact the Plan Administrator to determine the status of your Hour/Dollar Bank Account and the cost of benefits.

• Salaried Employees:

You are eligible to participate in the plan after 3 months of continuous employment. You are considered continuously employed only if you satisfy the actively at work requirement throughout the eligibility waiting period.

You must be actively at work when coverage takes effect, otherwise the coverage will be effective when you return to work.

Changes in Insurance

Increases in benefits while you or your dependents are in hospital will not become effective until you or your dependents are released from hospital.

Reinstatement Provision

If your coverage has terminated because of insufficient funds in your Hour/Dollar Bank Account, you will be eligible for reinstatement of your coverage:

1. If, within the 12 month period following termination of your coverage, on the first of the month following the date funds allocated to your Hour/Dollar Bank Account are sufficient to cover the current monthly cost of benefits; or

2. If, after the expiry of the 12 month period following termination of your coverage, on the first day of the month following the month in which you have accumulated 200 credited hours (straight time) and have sufficient funds in your Hour/Dollar Bank Account to cover the current cost of benefits.

If you are not working or available for work on the day your coverage would ordinarily reinstate, the coverage will be delayed until you return to active full-time work for one full day.

Termination Provision

Coverage for you and your eligible dependents will terminate on the earlier of any one of the following events:

• the end of the month in which the funds in your Hour/Dollar Bank Account are less than the required current monthly cost of benefits unless you remain a member in good standing of the Union and elect to continue your coverage under a self payment program (for up to a maximum period of 20 consecutive months only);

• when your membership in the Union is terminated (including resignation and expulsion) unless you have sufficient funds in your Hour/Dollar Bank Account to pay the current monthly coverage costs for all benefits except Short Term Disability and Long Term Disability Benefits. You are no longer entitled Short Term Disability and Long Term Disability Benefits when your membership in the Union is terminated;

• when you cease to be employed by the Union or an Employer;

• when you retire, unless you remain a member in good standing of the Union and elect to continue your coverage for the benefits available to you as a retired Union member under a self payment program;

• when premium payments cease;

• when you enter the military; and

• when the plan is discontinued.

Your dependents’ coverage will also terminate once they no longer qualify as an eligible dependent.

Extension Of Coverage By Self-Payment

Active Member: If your Hour/Dollar Bank Account depletes and you remain a member in good standing of the Union and you are available for work under the jurisdiction of the Union, you may continue coverage for yourself and your dependents on a consecutive monthly basis up to maximum of 20 months and chose from one of the following options:

Option 1: Continue coverage for all benefits including Dental, but excluding Short Term Disability and Long Term Disability

Option 2: Continue coverage for all benefits excluding Dental, Short Term Disability and Long Term Disability

Once you have elected either Option 1 (Benefit Class 2) or Option 2 (Benefit Class 7) you cannot change the option you have chosen until such time you are eligible to return to Class 1 or Retire or your Self-Payment time limit expires.

A member of the Union who is employed by a non-union or non-participating employer or who has refused a union call to work is considered or deemed not to be available for work under the jurisdiction of the Union and is not eligible to participate or continue to participate in the health plan self-payment program.

Retired Member: If you retire and remain a member in good standing of the Union, you may elect to continue coverage for reduced amount of Life Insurance for you and your dependents and reduced Health Care Benefits by making the required self payments.

This election must be made, and may only be made, at the time of your retirement. When your eligibility terminates, the Administrator will send a notice to you advising of the termination and the self-payment methods available.

Salaried Employees: Salaried employees of the Union are not eligible for extension of coverage by self payment.

Continuation Of Coverage While Disabled

If you are a member in good standing of the Union and are disabled and receiving WorkSafeNB benefits, Employment Insurance Sickness benefits or Disability Benefits under this plan, you will continue to receive your Life and Health benefits until the earliest of:

• the date you stop receiving WorkSafeNB Benefits, Employment Insurance Sickness benefits or Disability Benefits; or

• 6 months following the date of your disability.

Further options may be available. Please contact your Plan Administrator.

Survivor Benefits

If you die while your coverage is still in force, the health and dental benefits for your dependents will be continued for a period of 2 years or until they no longer qualify, whichever happens first.

DEPENDENT COVERAGE

Dependent means:

• Your spouse, legal or common-law.

A common-law spouse is a person who has been living with you in a conjugal relationship for at least 12 months.

• Your unmarried children under age 21, or under age 25 if they are full-time students.

Children under 14 days are not covered for dependent life insurance.

Children under age 21 are not covered if they are working more than 30 hours a week, unless they are full-time students.

Children who are incapable of supporting themselves because of physical or mental disorder are covered without age limit if the disorder begins before they turn 21, or while they are students under 25, and the disorder has been continuous since that time.

MEMBER LIFE INSURANCE

You may name a beneficiary for your life insurance and change that beneficiary at any time by completing a form available from your plan administrator. On your death, your organization will explain the claim requirements to your beneficiary. Great-West Life will pay your life insurance benefits to your beneficiary.

• If you are under age 65 and have been disabled for 6 months or more, you may be entitled to have your life insurance continued without premium payment until you reach age 65. You are considered disabled if injury or disease prevents you from being gainfully employed in any job. Great-West Life will determine your qualification for waiver of premium benefits. If you believe you may be eligible, contact your employer for claim forms. You must apply for waiver of premium benefits within 12 months of becoming eligible.

Retirees are not eligible for waiver of premium benefits.

• If any or all of your insurance terminates on or before your 65th birthday, you may be eligible to apply for an individual conversion policy without providing proof of your insurability. You must apply and pay the first premium no later than 31 days after your group insurance terminates. See your employer for details.

DEPENDENT LIFE INSURANCE

If one of your dependents dies, Great-West Life will pay you the dependent life insurance benefit. Your Plan Administrator will explain the claim requirements.

• If you are disabled and the premiums for your employee life insurance are waived, your dependent life insurance will also continue without premium payment until your own coverage terminates or your dependents no longer qualify.

Retirees are not eligible for waiver of premium benefits.

• If your spouse's insurance terminates on or before his or her 65th birthday, he or she may be eligible for an individual conversion policy without providing proof of insurability. You or your spouse must apply and pay the first premium no later than 31 days after the group insurance terminates. See your employer for details.

ACCIDENTAL DEATH, DISMEMBERMENT AND

SPECIFIC LOSS (AD&D) INSURANCE

If you suffer one of the losses listed below as the result of an accident which occurs while you are insured, Great-West Life will pay up to two times the Principal Sum. The loss must occur no later than 365 days after the accident. For loss of use, the loss must be continuous for 365 days. If you suffer multiple losses to the same limb as the result of the same accident, only the loss providing the highest amount payable will be paid.

The Principal Sum is the maximum amount that will be paid for all injuries resulting from the same accident. For paraplegia, hemiplegia, and quadriplegia, the maximum amount that will be paid for all injuries resulting from the same accident is two times the Principal Sum.

Loss Amount Payable

Life Principal Sum

Both hands or both feet Principal Sum

Sight of both eyes Principal Sum

One hand and one foot Principal Sum

One hand and sight of one eye Principal Sum

One foot and sight of one eye Principal Sum

Speech and Hearing in both ears Principal Sum

One arm or one leg 3/4 Principal Sum

One hand or one foot or sight of

one eye 1/2 Principal Sum

Speech 1/2 Principal Sum

Hearing in both ears 1/2 Principal Sum

Thumb and index finger or at

least 4 fingers of one hand 1/4 Principal Sum

All toes of one foot 1/8 Principal Sum

Loss of Use

Both arms and both legs

(quadriplegia) 2 X Principal Sum

Both legs (paraplegia) 2 X Principal Sum

One arm and one leg on the same

side of the body (hemiplegia) 2 X Principal Sum

One arm and one leg on different

sides of the body Principal Sum

Both arms or both hands Principal Sum

One hand and one leg Principal Sum

One leg or one arm 3/4 Principal Sum

One hand 1/2 Principal Sum

Your AD&D insurance terminates when you reach age 70 or when you retire, whichever is earlier.

Waiver of Premium

AD&D Insurance will be continued without further premium payment during any period your Life Insurance is being continued under the waiver of premium benefit. Your insurance under this waiver of premium will terminate automatically when this benefit terminates.

Surgical Reattachment

If you suffer the loss of a limb that is surgically reattached, Great-West Life will pay 50% of the amount that would have been payable if the loss had been permanent, regardless of the amount of use regained. The balance of the benefit will be payable if the reattachment fails and the reattached part is removed within one year after the reattachment was performed.

Repatriation

If you die as the result of an accident that is at least 150 kilometres away from your home, Great-West Life will pay up to $2,500 for the preparation and transportation of your body to the place of burial or cremation less any amounts paid under this plan's global medical assistance benefit.

Educational Benefit for Dependent Children

If benefits are payable under this benefit provision for your death, Great-West Life will pay the tuition fees for enrolling your dependent children as full-time students at a post-secondary institution. To qualify for an educational benefit, a dependent child must have been enrolled as a full-time student at a post-secondary institution at the time of the accident causing your death, or he must have been enrolled as a full-time student at the secondary school level at the time of the accident causing your death and enrols as a full-time student at a post-secondary institution within 365 days after the accident.

Great-West Life will pay up to 5% of the Principal Sum, or $5,000, whichever is less, for each year of full-time post-secondary school enrolment. Great-West Life will pay the educational benefit each year for a maximum of 4 consecutive years upon receipt of proof of full-time enrolment.

No benefits will be paid for tuition expenses incurred before the accident, or room or board or other ordinary living, travelling, or clothing expenses.

Family Transportation Benefit

If you are hospitalized more than 150 kilometres from your home as a result of an injury for which benefits are payable under this benefit provision, Great-West Life will pay the actual expense incurred less any amount paid for the same expenses under this plan’s global medical assistance benefit, up to $2,000, for transportation and lodging expenses for one family member to join you.

Benefits for lodging are limited to moderate quality accommodation for the area of hospitalization. Telephone expenses and taxicab and car rental charges are included. Meal expenses are not covered.

Transportation expenses are limited to round trip economy class transportation. If a private vehicle is used, expenses are limited to $.44 per kilometre travelled.

Occupational Training Benefit for Spouses

If benefits are payable under this benefit provision for your death, Great-West Life will pay for expenses associated with your spouse’s enrolment in an accredited occupational training program. The purpose of the training program must be to provide the spouse with at least the minimum qualifications required for employment in an occupation for which the spouse would not otherwise qualify.

Great-West Life will pay up to 10% of the Principal Sum, or $10,000, whichever is less.

No benefits will be paid for expenses incurred more than 3 years after the accident causing your death, or room or board or other ordinary living, travelling, or clothing expenses.

Educational Benefit

If benefits are payable under this benefit provision for an injury that requires you to change occupations, Great-West Life will pay the tuition fees for enrolling you as a student at a post-secondary institution for training in a new occupation. To qualify for an educational benefit, you must enrol at a post-secondary institution within 365 days after the accident. Great-West Life will pay up to $10,000.

No benefits will be paid for tuition expenses incurred before the accident, expenses incurred more than 2 years after the accident causing the injury, or room or board or other ordinary living, travelling, or clothing expenses.

Wheelchair Benefit

If benefits are payable under this benefit provision for an injury that requires the use of a wheelchair for you to be ambulatory, Great-West Life will pay for alterations to your principal residence to make it wheelchair accessible and habitable, and modifications to a motor vehicle you use to make it accessible to and driveable by you.

Benefits for home alterations are payable only if the person or persons making the changes are experienced in home alterations for wheelchairs, and recommended by an organization recognized for providing support and assistance to wheelchair users.

Benefits for vehicle modifications are payable only if the person or persons making the changes are experienced in vehicle modification for wheelchairs, and the modifications are approved by the provincial vehicle licensing authority.

Great-West Life will pay the actual expense incurred less any amount paid for the same expenses under this plan’s healthcare benefit, up to $10,000 for all home and vehicle modifications combined.

No benefits will be paid for expenses incurred more than 365 days after the accident, or for subsequent alterations to your home or vehicle after an initial claim for benefits has been made under this wheelchair benefit provision.

Limitations

No benefits are paid for injury or death resulting from:

• Intentionally self-inflicted injury or suicide

• Viral or bacterial infections, except pyogenic infections occurring through the injury for which loss is being claimed

• Any form of illness or physical or mental infirmity

• Medical or surgical treatment, except surgical reattachment

• War, insurrection or voluntary participation in a riot

• Service in the armed forces of any country

• Air travel serving as a crew member, or in aircraft owned, leased or rented by your employer, or air travel where the aircraft is not licensed or the pilot is not certified to operate the aircraft

How to Make a Claim

• To claim benefits for yourself, ask your plan administrator for a claim form. Complete it and return it to your plan administrator.

• If you die accidentally, your plan administrator will explain the claim requirements to your beneficiary.

• Claims should be submitted as soon as possible, but no later than 15 months after the loss.

Belmont Financial Group

Suite 110, Hilyard Place, Bldg. B, 580 Main St.

Saint John, NB E2K 1J5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

SHORT TERM DISABILITY (STD) INCOME BENEFITS

(Applicable to Benefit Class 1 and 16 only)

The plan provides you with regular income to replace income lost because of a disability due to disease or injury. Benefits begin after the waiting period is over and continue until you are no longer disabled or until the end of the benefit period, whichever comes first. Check the Benefit Summary for the benefit amount, waiting period and benefit period.

• STD benefits are payable after the waiting period if disease or injury prevents you from doing your own job. You are not considered disabled if you can perform a combination of duties that regularly took at least 60% of your time to complete.

• If you have not seen a physician before the end of the waiting period, benefits will not be payable until after your first visit to the physician.

• Separate periods of disability arising from the same disease or injury are considered to be one period of disability unless they are separated by at least 2 weeks of continuous work at the same number of hours per week as you regularly worked before the disability started.

• Because your employer contributes to the cost of STD coverage, benefits are taxable.

Other Income

Your STD benefit is reduced by other income you are entitled to receive while you are disabled. Other income includes:

• benefits under any Workers' Compensation Act or similar law

• benefits under a legislated automobile insurance plan where permitted by law

Earnings received from an approved rehabilitation plan or program are not used to reduce your STD benefit unless those earnings, together with your income from this plan and the other income listed above, would exceed your weekly earnings before you became disabled. If it does, your benefit is reduced by the excess amount.

Vocational Rehabilitation Benefits

Vocational rehabilitation involves a work related activity or training strategy that is designed to help you return to gainful employment and a more productive lifestyle. A plan or program will be approved if it is appropriate for the expected duration of your disability and it facilitates your earliest possible return to work.

Medical Coordination Benefits

Medical coordination is a process of early involvement to ensure that you are diagnosed quickly and receive appropriate treatment on a timely basis. The goal is to enable you to return to work as early as possible and to prevent the disability from becoming long term or permanent.

Limitations

No benefits are paid for:

• Any period in which you do not participate or cooperate in a prescribed plan of medical treatment appropriate for your condition.

Depending on the severity of the condition, you may be required to be under the care of a specialist.

If substance abuse contributes to your disability, the treatment program must include participation in a recognized substance withdrawal program.

• Any period you are eligible for Employment Insurance benefits.

• The scheduled duration of a lay-off or leave of absence.

This does not apply to any portion of a period of maternity leave during which you are disabled due to pregnancy.

• Any period of employment, except in an approved rehabilitation plan or program.

• Any period after you fail to participate or cooperate in an approved rehabilitation plan or program.

• Any period after you fail to participate or cooperate in a recommended medical coordination program.

• Disability due to or associated with cosmetic treatment.

• Any period of confinement in a prison or similar institution.

• Disability arising from war, insurrection or voluntary participation in a riot.

How to Make a Claim

Notify the Plan Administrator of your disability as soon as possible. Obtain a claim form from the Plan Administrator and follow the instructions. Please ensure that your claim is submitted to the Plan Administrator within 6 months after the onset of your disability.

Belmont Financial Group

Suite 110, Hilyard Place, Bldg. B, 580 Main St.

Saint John, NB E2K 1J5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

LONG TERM DISABILITY (LTD) INCOME BENEFITS

Applicable to Benefit Class 1 and 16 only

The plan provides you with regular income to replace income lost because of a lengthy disability due to disease or injury. Benefits begin after the waiting period is over and continue as long as you are disabled as defined by the policy but not longer than 5 years or until you reach age 65, whichever comes first. Check the Benefit Summary for the benefit amount and waiting period.

• If disability is not continuous, the days you are disabled can be accumulated to satisfy the waiting period as long as no interruption is longer than 2 weeks and the disabilities arise from the same disease or injury.

• LTD benefits are payable for the first 24 months following the waiting period if disease or injury prevents you from performing the essential duties of your regular occupation, and, except for any employment under an approved rehabilitation plan, you are not employed in any occupation that is providing you with income equal to or greater than your amount of LTD insurance under this plan, as shown in the Benefit Summary.

• After 24 months, LTD benefits will continue only if your disability prevents you from being gainfully employed in any job. Gainful employment is work you are medically able to perform, for which you have at least the minimum qualifications, and which provides you with an income of at least 50% of your indexed monthly earnings before you became disabled.

• Loss of any license required for work will not be considered in assessing disability.

• After the waiting period, separate periods of disability arising from the same disease or injury are considered to be one period of disability unless they are separated by at least 6 months.

• Because your employer contributes to the cost of LTD coverage, benefits are taxable.

• Your LTD insurance terminates when you reach age 65.

Other Income

Your LTD benefit is reduced if the total of it and the other income you are entitled to receive while you are disabled exceeds 80% of your monthly earnings before you became disabled. If it does, your benefit is reduced by the excess amount. Other income includes:

• disability or retirement benefits you are entitled to on your own behalf under the Canada Pension Plan or Quebec Pension Plan

• benefits under any Workers' Compensation Act or similar law

• loss of income benefits under an automobile insurance plan, to the extent permitted by law

• loss of income benefits available through legislation, except for Employment Insurance benefits and automobile insurance benefits, which you or another member of your family is entitled to on the basis of your disability

• the wage loss portion of any criminal injury award

• disability benefits under a plan of insurance available through an association

• employment income, disability benefits, or retirement benefits related to any employment except for income from an approved rehabilitation plan (termination pay, severance benefits, and any similar termination of employment benefits, including any salary paid in lieu of notice, are included as employment income under this provision)

Earnings received from an approved rehabilitation plan are not used to further reduce your LTD benefit unless those earnings, together with your income from this plan and the other income listed above, would exceed your indexed monthly earnings before you became disabled. If it does, your benefit is reduced by the excess amount.

Cost-of-living increases in the other income listed above, that take effect after the benefit period starts, except for income from an approved rehabilitation plan, are not included.

Vocational Rehabilitation

Vocational rehabilitation involves a work related activity or training strategy that is designed to help you return to your own job or other gainful employment, and is recommended or approved by Great-West Life. In considering whether to recommend or approve a rehabilitation plan, Great-West Life will assess such factors as the expected duration of disability, and the level of activity required to facilitate the earliest possible return to work.

Medical Coordination

Medical coordination is a program, recommended or approved by Great-West Life, that is designed to facilitate medical stability and provide you with cost effective, quality care. In considering whether to recommend or approve a medical coordination program, Great-West Life will assess such factors as the expected duration of disability, and the level of activity required to facilitate medical stability.

Limitations

No benefits are paid for:

• Disability arising from a disease or injury for which you received medical care before your insurance started. This limitation does not apply if your disability starts after you have been continuously insured for 1 year, or you have not had medical care for the disease or injury for a continuous period of 90 days ending on or after the date your insurance took effect.

• Any period after you fail to participate or cooperate in a prescribed plan of medical treatment appropriate for your condition.

Depending on the severity of the condition, you may be required to be under the care of a specialist.

If substance abuse contributes to your disability, the treatment program must include participation in a recognized substance withdrawal program.

• Any period after you fail to cooperate in applying for other disability benefits, reapplying for such benefits, or appealing decisions regarding such benefits, where considered appropriate by Great-West Life.

• Any period after you fail to participate or cooperate in an approved rehabilitation plan.

• Any period after you fail to participate or cooperate in a recommended medical coordination program.

• Any period after you fail to participate or cooperate in a required medical or vocational assessment.

• The scheduled duration of a leave of absence.

This does not apply to any portion of a period of maternity leave during which you are disabled due to pregnancy.

• Any period in which you are outside Canada. This exclusion does not apply during the first 30 days of an absence, or if Great-West Life pre-authorized the absence prior to your departure.

• Any period of incarceration, confinement, or imprisonment by authority of law

• Disability arising from war, insurrection, or voluntary participation in a riot.

How to Make a Claim

Before the end of the short term disability benefit period, Great-West Life will ask your Plan Administrator to provide information to begin processing your LTD claim. All information must be submitted within 6 months of the request.

Belmont Financial Group

Suite 110, Hilyard Place, Bldg. B, 580 Main St.

Saint John, NB E2K 1J5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

HEALTHCARE

All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information.

The plan covers customary charges for the following services and supplies. All covered services and supplies must represent reasonable treatment. Treatment is considered reasonable if it is accepted by the Canadian medical profession, it is proven to be effective, and it is of a form, intensity, frequency and duration essential to diagnosis or management of the disease or injury.

You are only covered for Healthcare benefits that apply to your Benefit Class as shown in the Benefit Summary.

Covered Expenses

• Ambulance transportation to the nearest centre where adequate treatment is available

• Home nursing services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, when services are provided in Canada, but only if the patient requires the specific skills of a trained nurse

Convalescent home nursing care for a condition that will significantly improve as a result of the care and follows a 3-day confinement for acute care

You should apply for a pre-care assessment before home nursing begins

• Drugs and medicines which require the written prescription of a physician or other person entitled by law to prescribe them, and are dispensed by a licensed pharmacist, as well as certain life-sustaining drugs, injectable drugs and syringes for self-administered injections, when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the out-of-country emergency care provision.

The plan will also pay for vaccines used to prevent disease

For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan.

• Rental or, at Great-West Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a physician

• Custom-made foot orthotics and custom-fitted orthopedic shoes, including modifications to orthopedic footwear are covered as follows:

When recommended by a Physician or Podiatrist:

a) Workboots

b) Stock-Item Orthopaedic Shoes; and

c) Modifications or adjustments to Stock-Item Orthopaedic Shoes or regular footwear

Charges will be subject to the Stock-Item Orthopaedic Shoes maximum of 1 pair of custom-made shoes per calendar year at reasonable and customary charges which are:

a) constructed by a Certified Orthopaedic Footwear Specialist; and

b) required because of a medical abnormality that based on medical evidence cannot be accommodated in a Stock-Item Orthopaedic Shoe or a Modified Stock-Item Orthopaedic Shoe

Charges for casted, Custom-Made Orthotics which are recommended by a Physician or Podiatrist up to the Custom-Made Orthotics maximum of 1 pair of Custom-Made Orthotics per calendar year.

For each claim and/or predetermination for Orthotics and Orthopedic Shoes, we will require that ALL of the following information be supplied:

- a diagnosis often condition (symptoms alone will not suffice)

- a list of symptoms and the chief complaint

We will not cover costs associated with off-the-shelf “sport” shoes i.e. Reebok, New Balance, Axik, Nike, etc.

In order to be eligible for payment we will also require that Orthotics and Orthopedic Shoes be prescribed, on an annual basis, by one of the following 3 providers:

• Medical General Practitioner or Specialist (MD)

• Podiatrist (DPM)

• Chiropodist (D CH or D Pod M)

As well, Orthotics and Orthopedic Shoes must be dispensed by one of the following 4 provider types:

• Orthotist CO (c) or CPO (c)

• Pedorthist C Ped (c) or C Ped (MC)

• Podiatrist (DPM)

• Chiropodist (D CH or D Pod M)

• Hearing aids, including batteries, tubing and ear molds provided at the time of purchase, when prescribed by a physician

• Speech aids, including Bliss boards and laryngeal speaking aids, prescribed by a physician when no alternative method of communication is possible

• Diabetic supplies, including insulin, syringes, Novolin pens, testing supplies and insulin infusion sets, when prescribed by a physician

• Blood-glucose monitoring machines prescribed by a physician

• External insulin infusion pumps prescribed by a physician

• Needleless insulin jet injectors prescribed by a physician

• Diagnostic x-rays and lab tests, when coverage is not available under your provincial government plan

• Treatment of injury to sound natural teeth. Treatment must start within 60 days after the accident unless delayed by a medical condition

A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced

No benefits are paid for:

- accidental damage to dentures

- dental treatment completed more than 12 months after the accident

- orthodontic diagnostic services or treatment

You are not eligible for Accidental Dental benefits under Healthcare if you have Dentalcare benefits.

• Out-of-hospital services of a qualified acupuncturist

• Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor

• Out-of-hospital services of a qualified massage therapist when referred by a doctor

• Out-of-hospital services of a licensed naturopath

• Out-of-hospital services of a licensed osteopath, including diagnostic x-rays

• Out-of-hospital treatment of movement disorders by a licensed physiotherapist or licensed athletic therapist

• Out-of-hospital treatment of foot disorders, including diagnostic x-rays, by a licensed podiatrist

• Out-of-hospital treatment by a registered psychologist or qualified social worker

• Out-of-hospital treatment of speech impairments by a qualified speech therapist

• Out-of-hospital services of a qualified audiologist

Visioncare

• Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist, and coverage is not available under your provincial government plan

• Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician

• Contact lenses prescribed by a licensed ophthalmologist or optometrist for severe corneal astigmatism, severe corneal scarring, Keratoconous (conical cornea) or Aphakia provided visual acuity cannot be improved to at least the 20/40 level by glasses

• Laser eye surgery required to correct vision when performed by a licensed ophthalmologist

For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit.

Global Medical Assistance Program

(Retirees and Closed Class 30 are not eligible for this benefit)

This program provides medical assistance through a worldwide communications network which operates 24 hours a day. The network locates medical services and obtains Great-West Life's approval of covered services, when required as a result of a medical emergency arising while you or your dependent is travelling for vacation, business or education. Coverage for travel within Canada is limited to emergencies arising more than 500 kilometres from home. You must be covered by the government health plan in your home province to be eligible for global medical assistance benefits. The following services are covered, subject to Great-West Life's prior approval:

• On-site hospital payment when required for admission, to a maximum of $1,000

• If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment

When services are covered under this provision, they are not covered under other provisions described in this booklet

• Transportation and lodging for one family member joining a patient hospitalized for more than 7 days while travelling alone. Benefits will be paid for moderate quality lodgings up to $1,500 and for a round trip economy class ticket

• If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent’s medical condition, to a maximum of $1,500

• The cost of comparable return transportation home for you or a dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation

• In case of death, preparation and transportation of the deceased home

• Return transportation home for minor children travelling with you or a dependent who are left unaccompanied because of your or your dependent’s hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary

• Costs of returning your or your dependent's vehicle home or to the nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of $1,000. Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home

Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.

Out-Of-Country Emergency Care

(Retirees and Closed Class 30 are not eligible for this benefit)

The plan covers medical expenses incurred as a result of a medical emergency arising while you or your dependent is outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province.

A medical emergency is a sudden, unexpected injury or an acute episode of disease.

• The following services and supplies are covered when related to the initial medical treatment:

- treatment by a physician

- diagnostic x-ray and laboratory services

- hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins while you or your dependent is covered

- medical supplies provided during a covered hospital confinement

- paramedical services provided during a covered hospital confinement

- hospital out-patient services and supplies

- medical supplies provided out-of-hospital if they would have been covered in Canada

- drugs

- out-of-hospital services of a professional nurse

- ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available

If your medical condition permits you to return to Canada, benefits will be limited to the amount payable under this plan for continued treatment outside Canada or the amount payable under this plan for comparable treatment in Canada, plus return transportation, whichever is less. No benefits are paid for expenses incurred more than 90 days after the date of departure from Canada. If you or your dependent is hospital confined at the end of the 90-day period, benefits will be extended to the end of the confinement.

Limitations

Except to the extent otherwise required by law, no benefits are paid for:

• Expenses private insurers are not permitted to cover by law

• Services or supplies for which a charge is made only because you have insurance coverage

• The portion of the expense for services or supplies that is payable by the government health plan in your home province, whether or not you are actually covered under the government health plan

• Any portion of services or supplies which you are entitled to receive, or for which you are entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government (“government plan”), without regard to whether coverage would have otherwise been available under this plan

In this limitation, government plan does not include a group plan for government employees

• Services or supplies that do not represent reasonable treatment

• Services or supplies associated with:

- treatment performed only for cosmetic purposes

- recreation or sports rather than with other daily living activities

- the diagnosis or treatment of infertility, other than drugs

- contraception, other than oral contraceptives

• Services or supplies not listed as covered expenses

• Extra medical supplies that are spares or alternates

• Services or supplies received outside Canada except as listed under Out-of-Country Emergency Care and Global Medical Assistance

• Services or supplies received out-of-province in Canada unless you are covered by the government health plan in your home province and Great-West Life would have paid benefits for the same services or supplies if they had been received in your home province

This limitation does not apply to Global Medical Assistance

• Expenses arising from war, insurrection, or voluntary participation in a riot

• Visioncare services and supplies required by an employer as a condition of employment

• Any drug or item which does not have a drug identification number as defined by the Food and Drugs Act, Canada

• Drugs administered during treatment in an emergency room of a hospital, or as an in-patient in a hospital

• Homeopathic preparations, unless federal or provincial legislation requires a prescription for their sale

• Drugs used to treat erectile dysfunction

How to Make a Claim

• Out-of-country claims (other than those for Global Medical Assistance expenses) must be submitted to your provincial Medicare Plan before you submit your claims to Belmont Financial Group at the address shown below.

• Obtain a claim form from your employer. Complete this form making sure it shows all required information.

• Attach your receipts to the claim form and return it to Belmont Financial Group as soon as possible, but no later than 15 months after you incur the expense:

Belmont Financial Group

Suite 110, Hilyard Place, Bldg. B, 580 Main St.

Saint John, NB E2K 1J5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

PREFERRED VISION SERVICES (PVS)

Preferred Vision Services (PVS) is a service provided by Great-West Life to its customers through PVS which is a preferred provider network company.

PVS entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding, tints, etc.) when you purchase these items from a PVS network optician or optometrist. A discount on laser eye surgery can be obtained through an organization that is part of the PVS network.

PVS also entitles you to a discount on hearing aids (batteries, tubing, ear molds, etc.) when you purchase these items from a PVS network provider.

You are eligible to receive the PVS discount through the network whether or not you are enrolled for the healthcare coverage described in this booklet. You can use the PVS network as often as you wish for yourself and your dependents.

Using PVS:

• Call the PVS Information Hotline at 1-800-668-6444 or visit the PVS Web site at pvs.ca for information about PVS locations and the program

• Arrange for a fitting, an eye examination, a hearing assessment or a hearing test, if needed

• Present your group benefit plan identification card, to identify your preferred status as a PVS member through Great-West Life, at the time the eyewear or the hearing aid is purchased, or at the initial consultation for laser eye surgery

• Pay the reduced PVS price. If you have vision care coverage or hearing aids coverage for the product or service, obtain a receipt and submit it with a claim form to your insurance carrier in the usual manner.

DENTALCARE

All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information.

The plan covers customary charges to the extent they do not exceed the dental fee guide level shown in the Benefit Summary. Denturist fee guides are applicable when services are provided by a denturist. Dental hygienist fee guides are applicable when services are provided by a dental hygienist practising independently.

All covered services and supplies must represent reasonable treatment. Treatment is considered reasonable if it is recognized by the Canadian Dental Association, it is proven to be effective, and it is of a form, frequency, and duration essential to the management of the person's dental health. To be considered reasonable, treatment must also be performed by a dentist or under a dentist’s supervision, performed by a dental hygienist entitled by law to practise independently, or performed by a denturist.

You are covered for only the Dentalcare benefits that apply to your Benefit Class as shown in the Benefit Summary.

Treatment Plan

• Before incurring any large dental expenses, ask your dental service provider to complete a treatment plan and submit it to Great-West Life. Great-West Life will calculate the benefits payable for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.

Basic Coverage

The following expenses will be covered:

• Diagnostic services including:

- one complete oral examination every 36 months

- limited oral examinations once each calendar year

- limited periodontal examinations once each calendar year

- specific and emergency examinations

- complete series of x-rays every 36 months

- intra-oral x-rays to a maximum of 15 films every 36 months and a panoramic x-ray every 36 months. Services provided in the same 12 months as a complete series are not covered

• Preventive services including:

- polishing and topical application of fluoride once each calendar year

- scaling, limited to a maximum combined with periodontal root planing of 10 time units every 12 months

A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval

- pit and fissure sealants on bicuspids and permanent molars every 60 months

- space maintainers including appliances for the control of harmful habits

- finishing restorations

- interproximal disking

- recontouring of teeth

• Minor restorative services including:

- caries, trauma, and pain control

- amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least 2 years old or the existing filling was not covered under this plan

- retentive pins and prefabricated posts for fillings

- prefabricated crowns for primary teeth

• Endodontics. Root canal therapy for permanent teeth will be limited to one course of treatment per tooth. Repeat treatment is covered only if the original treatment fails after the first 18 months

• Periodontal services including:

- root planing, limited to a maximum combined with preventive scaling of 10 time units every 12 months

- occlusal adjustment and equilibration, limited to a combined maximum of 4 time units every 12 months

A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval

• Denture maintenance, after the 3-month post-insertion care period, including:

- denture relines for dentures at least 6 months old, once every 36 months

- denture rebases for dentures at least 2 years old, once every 36 months

- resilient liner in relined or rebased dentures, once every 36 months

• Oral surgery

• Adjunctive services

Major Coverage

• Crowns. Coverage for crowns on molars is limited to the cost of metal crowns. Coverage for complicated crowns is limited to the cost of standard crowns

• Onlays. Coverage for tooth-coloured onlays on molars is limited to the cost of metal onlays

Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable

• Standard complete dentures, standard cast or acrylic partial dentures or complete overdentures or bridgework when required to replace one or more teeth extracted while the person is covered. Overdentures and bridgework are covered only when standard complete or partial dentures are not viable treatment options. Coverage for tooth-coloured retainers and pontics on molars is limited to the cost of metal retainers and pontics. Replacement appliances are covered only when:

- the existing appliance is a covered temporary appliance

- the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while the person is covered and as a result of the placement of an initial opposing appliance or the extraction of additional teeth.

If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth

• Denture-related surgical services for remodelling and recontouring oral tissues

• Denture and bridgework maintenance following the 3-month post-insertion period including:

- denture remakes, once every 36 months

- denture adjustments, once every 12 months

- denture repairs and additions, tissue conditioning and resetting of denture teeth

- repairs to covered bridgework

- removal and recementation of bridgework

Accidental Dental Injury Coverage

• Treatment of injury to sound natural teeth. Treatment must start within 60 days after the accident unless delayed by a medical condition

A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced

Limitations

If you do not apply for dentalcare coverage within one month after you become eligible, benefits will be subject to the following restrictions, unless the expenses are incurred solely as a result of an accident occurring after the coverage takes effect:

• Basic Coverage expenses are limited to $100 during the first 12 months of your coverage

• No benefits will be paid for Major Coverage expenses during the first 12 months of your coverage

No benefits are paid for:

• Duplicate x-rays, custom fluoride appliances, any oral hygiene instruction and nutritional counselling

• The following endodontic services - root canal therapy for primary teeth, isolation of teeth, enlargement of pulp chambers and endosseous intra coronal implants

• The following periodontal services - desensitization, topical application of antimicrobial agents, subgingival periodontal irrigation, charges for post surgical treatment and periodontal re-evaluations

• The following oral surgery services - implantology, surgical movement of teeth, services performed to remodel or recontour oral tissues (other than minor alveoloplasty, gingivoplasty and stomatoplasty) and alveoloplasty or gingivoplasty performed in conjunction with extractions. Services for remodelling and recontouring oral tissues will be covered under Major Coverage

• Hypnosis or acupuncture

• Veneers, recontouring existing crowns, and staining porcelain

• Crowns or onlays if the tooth could have been restored using other procedures. If crowns, onlays or inlays are provided, benefits will be based on coverage for fillings

• Overdentures or initial bridgework if provided when standard complete or partial dentures would have been a viable treatment option.

If overdentures are provided, coverage will be limited to standard complete dentures.

If initial bridgework is provided, coverage will be limited to a standard cast partial denture and restoration of abutment teeth when required for purposes other than bridgework

If additional bridgework is performed in the same arch within 60 months, coverage will be limited to the addition of teeth to a denture and restoration of abutment teeth when required for purposes other than bridgework

Benefits will be limited to standard dentures or bridgework when equilibrated and gnathological dentures, dentures with stress breaker, precision and semi-precision attachments, dentures with swing lock connectors, partial overdentures and dentures and bridgework related to implants are provided

• Orthodontic treatment

• Accidental dental injury expenses for treatment performed more than 12 months after the accident, denture repair or replacement, or any orthodontic services

• Expenses private plans are not permitted to cover by law

• Services and supplies you are entitled to without charge by law or for which a charge is made only because you have insurance coverage

• Services or supplies that do not represent reasonable treatment

• Treatment performed for cosmetic purposes only

• Congenital defects or developmental malformations in people 19 years of age or over

• Temporomandibular joint disorders, vertical dimension correction or myofacial pain

• Expenses arising from war, insurrection, or voluntary participation in a riot

How to Make a Claim

Obtain a claim form from your employer. Have your dental service provider complete the form and return it to Belmont Financial Group at the address below as soon as possible, but no later than 15 months after the dental treatment:

Belmont Financial Group

Suite 110, Hilyard Place, Bldg. B, 580 Main St.

Saint John, NB E2K 1J5

Phone: (506) 634-7050

Toll Free 1-800-565-7050

Fax: (506) 634-6371

COORDINATION OF BENEFITS

• Benefits for you or a dependent will be directly reduced by any amount payable under a government plan. If you or a dependent are entitled to benefits for the same expenses under another group plan or as both an employee and dependent under this plan or as a dependent of both parents under this plan, benefits will be co-ordinated so that the total benefits from all plans will not exceed expenses.

• You and your spouse should first submit your own claims through your own group plan. Claims for dependent children should be submitted to the plan of the parent who has the earlier birth date in the calendar year (the year of birth is not considered). If you are separated or divorced, the plan which will pay benefits for your children will be determined in the following order:

1. the plan of the parent with custody of the child;

2. the plan of the spouse of the parent with custody of the child;

3. the plan of the parent without custody of the child;

4. the plan of the spouse of the parent without custody of the child

You may submit a claim to the plan of the other spouse for any amount which is not paid by the first plan.

DIAGNOSTIC AND TREATMENT SUPPORT SERVICES

(BEST DOCTORS® SERVICE)

This service is designed to allow you, your dependents and your attending physician or specialists access to the expertise of world-class specialists, resources, information and clinical guidance.

If you or your dependents are diagnosed with a serious medical condition for which there is objective evidence, or if your physician or you or your dependent suspect you have this condition, you can access this service. This service is made up of a unique step-by-step process that may help address questions or concerns about a medical condition. This may include confirming the diagnosis and suggesting the most effective treatment plan by drawing on a global database of up to 50,000 peer-ranked specialists.

How it works

• You or your dependent can access diagnostic and treatment support services by calling 1-877-419-BEST (2378) toll-free.

• You will be connected with a member advocate who will be dedicated to your case and will provide support through the process. The member advocate will take the necessary medical history and answer your questions. Any information provided is not shared with either your employer or the administrator of your health plan.

• Based on the information and questions, the member advocate determines the optimal level of service for you or your dependent.

• The member advocate may provide information, resources, guidance and advice individually tailored to meet your health needs. They can also help identify individual community supports and resources available.

• If it is appropriate, the member advocate may arrange for an in-depth review of your medical file to assist in confirming the diagnosis and help develop a treatment plan. This review may include collecting, deconstructing and reconstructing medical records, pathology retesting and analyzing test results. A written report outlining the conclusions and recommendations of the specialists will be forwarded to you and your physician. On average, this process takes 6 to 8 weeks. Timeframes may vary depending on the complexity of the case and amount of medical records to collect.

• If you decide to seek treatment by a different physician, the member advocate can help identify the specialist best qualified to meet your specific medical needs. Expenses incurred for travel and treatment are not covered by this service.

• If you decide to seek treatment outside Canada, the member advocate can arrange referrals and can help book accommodations. The member advocate can also access hospital and physician discounts, arrange for forwarding of medical information and monitor the treatment process. Expenses incurred for travel and treatment are not covered by this service.

Note: These services are not insured services. Great-West Life is not responsible for the provision of the services, their results, or any treatment received or requested in connection with the services.

The Board of Trustees reserve the right to change or eliminate Group Health Insurance benefits for members in one or more Classes.

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